Rebecca Vesely: This is Rebecca Vesely, reporter with Modern Healthcare magazine, and today we have the pleasure of talking to Drew Altman, president and CEO of the Kaiser Family Foundation. Welcome, Drew. So you've been named to our list of the 100 Most Powerful People in Healthcare for the ninth year in a row, and I'm wondering if you can reflect a little bit on how the Kaiser Family Foundation has grown and changed in those nine years?
Drew Altman: I don't know. I suspect that most of the so-called ‘powerful people' on your list feel pretty powerless. At least the ones who are sensible would. You know, we're still a relatively young organization in that we really created the organization afresh—while it's existed technically or legally since the late '40s—I came out to California to start a new organization, a new Kaiser Foundation, really in 1990, 1991. I expected to be here just about five years, but I'm still here. We built a new organization in the early '90s, so as healthcare organizations go, as policy organizations and foundations, we're still a relatively new organization. And what we set out to do was build an organization that could play a special role and a trusted source of information and analysis—kind of a counterweight to the vested interests in healthcare, the dominance of money and politics in our field, and we're still in the process of building that institution. Building our capacity to play that role. So we have lots of programs and projects, and people see little glimpses of us and maybe a website here or there or a study or a poll. Other people know other work we do, like our big media campaigns around the world or our news service. But it's all really part of building the institution that can play the role that we set out to play. In 1991, when we announced to the world, ‘OK, here we are, and this is what we're going to try and do …'
Rebecca Vesely: I want to go back to something that you said. You said that ‘You imagine some of the people on the list feel powerless'—
Drew Altman: Just cause it's a giant healthcare system and it's very hard for any organization or institution, or even the president or the Congress, to really influence on their own. So I think the trick, or to put it more narrowly, really the trick if you are in a foundation, but we don't make grants. We're kind of a peculiar kind of foundation, a one-of-a-kind kind of foundation—legally, we're called an ‘operating foundation'—is to find a special role that you can play. In a giant system, you're not going to change it all by yourself. You have to find your role, your way that you can make a contribution. And the answer to the question: What is our role? What is our strategy? What is our niche? is going to be a little different for everybody, depending upon your history and your resources and just cards you should have to play. Everyone should have just a little bit different answer to that question. It would actually be, I think, a problem if everyone tried to do what we do, and they don't thankfully.
Rebecca Vesely: One of your biggest jobs now is providing unbiased information about the health reform law, and you said that you see some of the biggest challenges to implementation being in the States. Why do you think that?
Drew Altman: Well, first of all, yes, we are, among the many things that we're doing here, gearing up across the board all the things we do for the implementation of health reform. And actually I think that that will, in some ways, that will be a bigger challenge and also a bigger opportunity for us than when we were in the middle of the friendly debate. Because not every analyst, every researcher, every pundit and every elected official will be in health reform. So actually I think there will be a bigger demand on us as we slog through years of implementation than there was during the sort of incredible intensity of the legislative debates itself. So we're gearing up for that, and, you know, and what we want to do is, first of all, play a role in just trying to be a place that establishes what are the facts about what the legislation does and doesn't do, especially in what I expect to be sort of the continued craziness of the midterm election year. Secondly, trying to inform the critical early implementations that are made at the federal and state level. I think third, because we're known for trying to give people a voice, so to speak, at the table, and especially different groups who might not have a seat at the table, through our polling and survey research, trying to do that. And, ultimately, then, and it will take years to do this because the law isn't fully implemented for years, just to gauge the impact of the legislation itself. So, you asked about states, I will admit as a former state human services commissioner who ran one of these big state's umbrella agencies some years ago, I am sort of immediately drawn to—or at least understand that state perspective in a personal way—but I do think a lot of what happens with this law, success or failure, will rely on the ability of the states to carry out their huge implementation responsibilities—whether it's the Medicaid expansion of the law or setting up the new insurance exchanges or overseeing the new rules and regulations for health insurance and more than that. It isn't so much about what I think I appreciate as a former state official, and I was also a federal one, but it isn't so much about: Some states are [unclear], some states are for it. It's more the capacity for states to really do the job at a time when they're still struggling with the aftereffects of the recession. State money is short. State staff has been cut back. Just their ability to take on arguably the biggest implementation challenge in the history of domestic programs, or certainly one of the biggest ones.
Rebecca Vesely: And the cost of healthcare continues to go up. What do you see as the most promising areas for cost savings?
Drew Altman: Well, you know, I think cost containment is a tough challenge for the country, and hopefully the way I would put it is they built into the law everything that was politically doable right now. And we don't know which of those things will really take and which won't. They'll all be implemented, and we will see. What I'm more concerned about is that without a big answer on controlling costs in health, we're in an era when we resorted instead, our answer has been more to just ask average working people to pay more. And that placed a real financial burden on average people. And while certainly there's an argument for appropriate cost sharing in health insurance, there's also a fine line. And when we cross that line it becomes a real burden for people, and that's really what led to the health reform debate—the concerns that average people have about their ever-increasing health insurance bills. And while we've been focused on expanding insurance coverage, I think what's been missed, the kind of debate we never had in this country—still haven't had—is that what we call health insurance is actually changing fundamentally at the same time as insurance becomes skimpier and skimpier and less and less comprehensive. Higher deductibles, more cost sharing, that's something that we really need to focus on more. It explains two things: We're seeing moderating premium increases in the last several years—not just because there's a recession, but because when people pay more and more, it holds back the utilization of health services. But it also explains why even as we're in an era when economists see premium increases coming down, people are more upset than they've ever been about healthcare costs, and that's because they're paying a larger share of the bill.
Rebecca Vesely: Well your annual employer health benefit survey, which comes out next month, has been a touchstone for a lot of people in the industry on cost sharing and how much consumers are paying, can you give us any clues of what we're going to see next month?
Drew Altman: I can't give you a preview of the survey, but I expect our annual employer survey and the other work that we're doing to just continue to document the erosion of health insurance coverage, growth of high-deductible plans, the increase in cost sharing for just average working people, the phenomenon we've been seeing for many, many years now where things are really worse in the small group market. And while that isn't a focus of our upcoming survey, even in the nongroup or individual market we have another survey that we put out on that just a couple of months ago, which is what we hope to see fixed through the exchanges—
Rebecca Vesely: Well, I hate to end on a down note. Is there anything positive that we can say to wrap this up?
Drew Altman: Yeah. I think that while there obviously are different views about the health reform legislation, I think it's hard not to say that it represents—it's not only historic legislation—but tremendous progress that leads to the expansion of coverage for at least 30 million people who didn't have it. And fundamental reform of health insurance fixing for the first time all of the worst of the insurance system, which have been of such great concern for a broad cross section of the American people. And it makes a start on cost containment. So, whatever it does, it does. And ultimately will do on cost containment—that is really substantial progress. And whatever your views about the role of government and the legislation overall, it's hard not to see that as a major step forward.
Rebecca Vesely: Well, thanks Drew Altman for taking the time. We appreciate it.
Drew Altman: You're very welcome.
Rebecca Vesely: This is Rebecca Vesely for Modern Healthcare.
